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42A805-K5 (6-14-18 DRAFT) Page 1 of 2

Kentucky Withholding Account Number Federal Employer Identification Number (FEIN)

Business Name

Mailing Address (Number and Street including Apartment Number or P.O. Box)

City, Town or Post Office State ZIP Code Telephone Number

KENTUCKYEMPLOYER’S REPORT OF

WITHHOLDING TAX STATEMENTS*180001XXXX* 2018K-5

Commonwealth of Kentucky

Department of Revenue

FOR

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Part I—Kentucky withholding statement code and totals.

Mail To:

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PaidPreparerUse

Signature of Taxpayer Date

Name of Taxpayer Title

Signature of Preparer Date

Name of Preparer or Firm PTIN

Email Telephone No. May the DOR discuss this return with this preparer?¨ Yes ¨ No

Under penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Kentucky Department of RevenueK-5 ProcessingP. O. Box 181, Station 57Frankfort, KY 40601-2103

Total Kentucky Income Tax Withheld

Total Kentucky Wages or Payments

Number of Kentucky Withholding Statements

Withholding Statement Code (see instructions)

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Part II—Complete the table below for each statement or information return issued.

Taxpayer Identification Number Last Name Kentucky State Kentucky State (SSN or FEIN) (Employee or Payee) Wages or Payments Income Tax Withheld

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Page 2 of 2

42A805-K5 (6-14-18 DRAFT)

KENTUCKYEMPLOYER’S REPORT OF

WITHHOLDING TAX STATEMENTS*180001XXXX*FORM K5 (2018)

Kentucky Withholding Account Number

Taxpayer Identification Number Last Name Kentucky State Kentucky State (SSN or FEIN) (Employee or Payee) Wages or Payments Income Tax Withheld

26 or more must be filed electronically

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FORM K-5 INSTRUCTIONS 201842A805-K5(I) (8-16-18 DRAFT)Commonwealth of KentuckyDEPARTMENT OF REVENUE

Who Must File—Employers and payers who issue fewer than 26 Kentucky withholding tax statements W-2, W-2G or 1099’s and who are unable to file them electronically. Forms 1099 should only be reported if Kentucky income tax was withheld.

Employers and payers who issue 26 or more Kentucky withholding tax statements W-2, W-2G or 1099’s must file electronically. Electronic filing is preferred for all taxpayers to speed processing and reduce errors. For more information on filing electronically, please call (502) 564-1900 and select option 3.

When and where to file—Revenue Form K-5 must be mailed to the Department of Revenue, W-2 Processing, Station 57, 501 High Street, Frankfort, Kentucky 40601, on or before January 31 of the following year or the next business day if the due date falls on a weekend or legal holiday. Do not submit copies of Forms W-2, W-2G, or 1099. Please retain copies for your records.

Employer or payer account information—Enter the Kentucky withholding account number, Federal Employer Identification Number (FEIN), business name, and mailing address.

Part I—Kentucky withholding statement code and totals—Enter the Withholding Statement Code using the key below for the type of form being reported, the total number of Kentucky Withholding Statements (must be under 26), the total Kentucky wages or payments, and the total Kentucky income tax withheld.

Complete a separate Form K-5 for each form type—W-2, W-2G, 1099-R, 1099-MISC, or other 1099’s.

1 – W-2 2 – W-2G 3 – 1099-R 4 – 1099-MISC 5 – All other 1099’s

Part II—Kentucky withholding statement information—Enter the following for each Kentucky withholding statement: Taxpayer Identification number (Social Security Number or FEIN), Employee or Payee last name or entity name if reporting an FEIN (up to 9 characters), Kentucky wages or payments, and Kentucky income tax withheld.

Only report Kentucky withholding statements—Do not include statements for other states. This form will be reconciled with your annual reconciliation, Form K-3 or K-3E, and payments remitted.

Enter the following for each statement:

• W-2—Enter box 16, Kentucky State Wages, Tips, or Payments and box 17 for Kentucky income tax withheld.• W-2G—Enter box 14, Kentucky winnings, as Kentucky State Wages and Payments and box 15 for Kentucky

income tax withheld.• 1099-MISC—Enter box 18, Kentucky Income, as Kentucky State Wages or Payments and box 16 for Kentucky

income tax withheld.• 1099-R—Enter box 14, Kentucky Distribution, as Kentucky State Wages or Payments and box 12 for Kentucky

income tax withheld.

Only report Forms 1099 when Kentucky tax has been withheld.

Form W-2C, Corrected Wage and Tax Statement—Corrections can only be made via paper and should be reported by filing Form W-2C, not FORM K-5.